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Tuesday, October 18, 2011

When the G's and P's do not Align

It was 3 a.m. on a Saturday night, midway through my intern year, when the impact of pregnancy loss first slapped me in the face. As intern, I was in charge of doing the paperwork for all those being admitted to the hospital that night. The last patient on my list was a pleasant 50 year old women being admitted for pelvic pain.

In my rush to finish the paperwork and hopefully get an hour of sleep, I began hammering her with my list of questions. I started with, what every good OB/GYN intern starts with, the "G's and P’s". G=Gravida, which stands for the number of pregnancies. P=Parity, which stands for the number of deliveries. Each piece of the gynecological medical record starts with this bit of information. Yes, OB/GYNs start first by judging the ability of your womb to accept and carry a child.

“How many times have you been pregnant?” I ask hurriedly, pencil in hand.

“Only once.. but … he didn’t make it.” She said, her voice shaking, with a single tear quickly wiped from her cheek.

I was taken aback, both by her response and my own. This loss had occurred years ago, yet still stung so deeply. That night I learned to ask this question more tactfully.

A couple years later, I learned another lesson in the pain of pregnancy loss when my own joy of conceiving was quickly mired by seeing blood stained toilet paper. My loss was early, but the pain was deep and real. Time has healed my hurt, but I am frequently reminded of the pain of loss as I am often the bearer of bad news. Sadly, miscarriage is extremely common and something I had dealt with on a regular basis, but I had not truly appreciated the level of loss experienced, until I was on the other side of the stethoscope.

Over the years I learned to look differently at the G’s and P’s on the medical record. My heart will ache when I see a G6P2, realizing the painful reality that the 4 losses must represent. I cannot fathom feeling your heart sink so deep with disappointment, not just once, but 4 times.

October 15 is pregnancy and infant loss day. A time to remember and acknowledge the loss and pain that occurs when the G’s and P’s do not align. For those of you who have have experienced this loss, I cannot say I know how you feel, for everyone processes loss differently. I can say that I acknowledge that your pain is real and I pray that in your journey, you find peace and healing.

My lovely mother, who married my dad who was widowed w/ 2 babies, had an atopic pregnancy the year before giving birth to my youngest brother. She's in her mid-50's now and you can still hear the hurt in her voice when she remembers that pregnancy. My heart goes out to all those who have lost a child of any age.

Thank you so much for this. I am a mother in medicine who is a G4 P4 L3 A1, which looks straightforward at first glance, but it's not.

Our first baby died at 18 months, so that's a G and P but not an L. My second pregnancy was a twin-to-twin transfusion where one twin died at 18 weeks, happily the bigger twin is alive and well, so that's a G and a P but also one A and one L. My third and fourth pregnancies were straightforward, adding in my final Gs, Ps and Ls.

I too tread gently when asking about pregnancy history. I am so much braver than I used to be about asking details of losses and am always interested to hear and record the stories. I got so tired in my fourth pregnancy of having to explain my "numbers" to everyone -- sometimes I just lied actually :) -- there's a beautiful poem I read once asking for your dead children's forgiveness when you do that. You never forget.

I have had 3 miscarriages (2 this year) and for some reason the last one was the worst for me, even though I almost expected it (in fact I demanded an early U/S at 7 weeks because I just had a bad feeling - the time before I found out at 11 weeks and didn't want to wait that long again).

Thanks for your post. I know this is a common thing and for some reason it makes me feel better to know that I'm not alone but that it also doesn't mean I should just "get over it" because it is so common.

As a G3 P3 L2 mother, I often cringe when asked how many children I have. I will always love and remember my first daughter, but it makes me uncomfortable when I am forced to respond to the phrase, "I am so sorry". While it is easy enough to say "me too", the line of questions that follow can distract from the actual reason that I am at the doctors office. This is especially true when the surprised questioner tries to demonstrate their sympathy with a line of follow-up questions, statements in which they try to imagine how I feel (such as "you must be..."), and apologies such as "I had no idea".

I sometimes wonder if it is worth the anxiety of mentioning my first daughter ...and I really do not have a good answer because I also have anxiety when I do not mention her at all.

Thank you for acknowledging the anxiety of both the physician and the patient when we go through these "routine" questions.

I lost a pregnancy to an ectopic 3 months into my OBGYN internship. My first day back at work I had to deal with a fetal demise in emerg. Every time I see these women in emerg it brings everything rushing back; however, I'm grateful for this painful experience as it gives me insight and empathy for these patients. I definitely see the A's differently now.

I had two early losses when we were trying to get pregnant, and am currently 6 months +. While I do agree with Fizzy that it's been easier for me to get past my losses since I've managed to stay pregnant this time (knock on wood), I have to say that it means so much to me when a doctor I see approaches the issue with sensitivity. Not everyone does this. Several providers I saw before this pregnancy completely dismissed the losses, and a few were actively insensitive. In a way, I'm glad to have gone through this experience, because I think it will improve my empathy. On the other hand, it was really horrible at the time.

I think there is so much pain in this world, we just can't possibly fathom everyone's experiences. I too miscarried - at 14 weeks. I already have 3 beautiful children, but still tear up when I think about it. It still seems so strange to me that I am so emotionally tied to a child I never saw, but "expected". It's not easy to talk about, because so many women don't understand how you can still be emotional about a baby you never met.

Going into hospital as an almost 39 year old G4P0 (1 ectopic, 1 SA, 1 heterotopic) when my daughter was born, I realized that *I* was now the patient that I really worried about when I did my Obstetrics rotations, as in "I really hope nothing goes wrong as she doesn't have a lot of time left to try again". It momentarily freaked me out to think about it from the other perspective ...

I've never thought of this question from a doctors perspective. They don't usually make eye contact with me and I just figured it was routine. I just experienced my second miscarriage last week and am still grieving. I underwent my first D & C, one of the worst experiences of my life. I didn't know whether to be happy the baby was out of me or sad that I made it leave?? I have two kids, one of my miscarriages was between their two births and now this one, after their births. Now I'm scared to keep trying??? My doctor has been amazing through it all but it still is soo hard to say and wrap my mind around G4 P2....

I am a G7 P5 - and so blessed for those 5 (always!). But there were many tears shed for the two that were lost. I found that my subsequent pregnancies were filled with nightmares of lying in a pool of blood, and waking up too terrified to check the sheets.

But, as with you, I have found that my losses have given me such greater insight in my doctoring. I can now relate to the desperate fear in a woman's eyes when she presents in ED with spotting, and I understand the term a "precious baby" when I see a heavily weighted "G" score, and have learned to push the radiologist for that after-hours ultrasound...

Mothers in Medicine is a group blog by physician-mothers, writing about the unique challenges and joys of tending to two distinct patient populations, both of whom can be quite demanding. We are on call every. single. day.

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